Program Integrity

Provider fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to that individual or some other person. It includes any act that constitutes fraud under applicable federal or state law.

Examples include, but are not limited to:

• Altering a member’s medical records to generate fraudulent payments
• Billing for services or supplies that were not rendered or provided
• Billing for more costly services than those that were rendered (upcoding)
• Billing for group visits, such as a provider billing for several members of the same family in one visit, although only one family member was seen or provided with medically necessary services
• Misrepresenting services provided (for example, billing a covered procedure code but providing a noncovered service)
• Billing more than the charge to the general public
• Billing for services provided by unqualified or unlicensed personnel
• Soliciting, offering or receiving a kickback, bribe or rebate from medical providers for referrals or use of a product or service

Provider abuse means provider practices that are inconsistent with sound fiscal, business or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary costs to the Medicaid program.

Examples include, but are not limited to:

• Rendering or ordering excessive services, especially diagnostic tests
• Submitting claims for services inconsistent with the diagnosis and treatment of the member
• Rendering or ordering medically unnecessary services
• Poor or unsatisfactory quality of care provided to a member
• Billing the member for remaining balance after Medicaid payment
• Violating any of the provisions of the provider agreement

Potential consequences to the provider depend on the intent demonstrated and the severity of the activity.

Examples include, but are not limited to:

• Criminal investigation and/or prosecution
• Civil monetary penalties
• Exclusion by the Office of the Inspector General from Medicare and/or Medicaid, permanently or for a period of time
• Referral to the Indiana Professional Licensing Agency
• Prepayment review
• Payment suspension
• Recoupment of Medicaid overpayment
• Other administrative remedies

Provider waste includes practices that, directly or indirectly, result in unnecessary costs to the Medicaid program, such as overusing services. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources.